Monday, November 28, 2016


       Earlier in 2016, COL Robert B. Lim, MD, U.S. Army, edited a landmark text Surgery during natural disasters, combat, terrorist attacks, and crisis situation. I had the opportunity to chat with Dr. Lim about his text. Having been deployed numerous times into the zone of combat, I believe he can be considered an expert in this area. Several chapters peaked my interest (especially the one on unexplored ordinances), but the chapter written by Seon Jones and Gordon Wisbach on "Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation" interested me most due to the details provided on trauma teamwork in the combat environment. Trauma teamwork is difficult enough under normal circumstances, but just imagine managing a team in remote or hostile environments.

           In their chapter Jones and Wisbach reinforce the need for strict organization and planning. There is no room for error. They reiterate that success starts with Mass Casualty Planning and Rehearsal. After arrival to the operational area the team should discuss and rehearse the casualty plan. Preparation includes memorizing the layout of the trauma area, the facility as well as the outlying areas. Defined team positions and roles are key to avoid confusion and delays. In spite of the appearance of redundancy, prior to each incoming casualty, stating names and roles avoids confusion. Continued repetition focuses the team and reminds the team about potentially forgotten measures (PPE, civil closed loop communication). Team member names should be readily visible on each member to assure communication is clear and avoid distractions. Supplies and equipment need to be in standardized placement close to the immediate resuscitation area to avoid excess noise in asking or searching for supplies.  Each team member has an assigned checklist posted at their work station (detailed summary of those checklists noted in their chapter). The trauma team leader (TTL) should stand in a routine position where they have continued observation of the team (i.e. Foot of bed). One examiner is then on one side of the patient and the other examiner or RN on the other. Anesthesia should be at the head of the bed. Prior to patient arrival, each member needs to confirm their checklist has been reviewed. Team review should remind the team that only the TTL should be providing resuscitation instructions thereby avoiding the confusion that results from too many members instructing the team. A hierarchal structure helps to maintain the TTL's situational awareness. The TTL needs to remember to take a pause for summarization prior to and after critical steps in the resuscitation process- preintubation, post-BP stabilization- to avoid missing crucial details. The authors remind us that in spite of combat casualties occurring in austere environments, following standard clinical practice guidelines (CPG's) is vital- just because you may be remote, standard evidence-based protocols avoid conflict and improve team dynamics. Several other reminders of TTL roles are highlighted in this chapter.

              Finally the authors remind us of three vital team leadership roles- 1. watch for and control team stress and conflict 2. Be cognizant of Bruce Tuckman's revised stages of group development (forming, storming, norming, performing, and adjourning) to assure your team is developing appropriately 3. Morale retention and support from "compassion fatigue" is necessary to survive the arduous often primitive conditions. 

I immediately had a few questions for the authors and when I met up with Gordon Wisbach at the Excelsior meeting in advance of the ACS Clinical congress he agreed to discuss these.

1.      I constantly hear from surgeons that checklists and teamwork principles have no place in emergency or life-threatening situations.  When we discuss following the WHO and checklist principles, frequently heard complaints are: "the patient is dying! following these recommendations simply wastes valuable time and is not necessary".  I hear the complete opposite in your assessment of how to manage a team in life-threatening poorly supplied environments. Have you had success in
promoting these principles in civilian arenas? If yes, how do you convince others that moving fast without direction and rehearsal may slow you down?

Part of the reason for the usual resistance against check lists: Long, detailed, rigid, generic, all-inclusive checklist are arduous to follow and meaningless in some locations.  Checklist for emergency/life-threatening situations/crises should be developed differently than those designed to be implemented in a controlled, mindful setting.  A good analogy is a checklist prior to take off of a plane where you should take your time and focus on not missing key safety measures versus checklist that pilots and crew take during in-flight emergencies where seconds matter.  Even in the second scenario, they run through a checklist efficiently and effectively without error even though most medical personnel would think that it would slow the pilot down and the plane would crash before he even opens up the checklist.  

The reason the emergency checklist works is because they practice and drill the list so that ALL of the important steps are taken in a specific sequence without fail.  This is the principle we are very resistant to apply for major trauma resuscitations.  What we don't realize is that, as medical professionals, we already subscribe to the checklist principle whenever we take ACLS and BLS courses or do ACLS drills.  We practice those drills with the algorithms printed out on cards as cognitive aids, but we know the important first steps of that checklist by heart: 1. Open the airway, 2. Give breaths, 3. If no pulse, start compressions, 4. When the AED or crash cart arrives, check rhythm, 5. Shock or give drugs, etc.

The emergency checklists should be designed considering the frame of mind of someone who is in the emergency situation, traumatic injuries in our case.  After developing the list, it should be drilled and tested.  The actual emergency situation should not be the first time a team or an individual goes through the checklist.  It should be deliberately practiced and drilled.  Also, in this process, you may discover that some steps in your checklist are not appropriate (not practical, not useful, counterproductive, etc.)

In regard to, in your words, convincing others that moving fast without direction and rehearsal may actually be counterproductive, those others should try to remember those times when they just jumped into doing a procedure without all the necessary equipment, supplies, and set up.  They may have been all gowned up and gloved, but the patient was not prepped, yet, the chest tube was not in the room, there were no drapes, no scalpel, no hemostats, no drugs for sedation and the patient is moving too much, etc.  The patient received paralytics, but you didn't get the laryngoscope, didn't check the light was or was not working, now you're bagging him, but the O2 tank is empty, who checked the O2 tank? Ok, now the laryngoscope is here, but you can't see cords, oops we didn't plan for a difficult airway, no fiberoptics, no bougie, no LMA, need a surgical airway, stat? where is the scalpel, where is the crich tube or the 4-0 endotracheal tube, etc.

2.      When you first went into action, what preconceived notions were instantly proven false?

The preconceived notion that only the medical providers were essential personnel is false.  In a resource and personnel scarce environment, everyone is vital to running an ongoing casualty receiving area.  For optimal throughput, all the steps from restocking supplies, preparing the room for a resuscitation, litter bearing, and cleaning to be ready for the next casualty are important steps.  Nothing conveys the importance of these details than actually carrying out these tasks yourself when you can.  It's like pre-flighting your trauma bay/ED/OR like a pilot pre-flights or looks over the aircraft he is about to fly.

3.      When you arrived at a designation, was there anything that totally caught you by surprise?

In retrospect, it is incredibly rare to see the type of multi-dimensional injuries of blast casualties in any civilian setting.  The only similar situations I can recall off the top of my head are the Boston Marathon bombing, the Oklahoma bombing, and may be 9/11.  It would be much simpler in comparison to have straight forward gunshot wounds or blunt trauma from a fall or MVC.  The war time casualties come with the myriad of unique injuries characterized by blast injuries.

4.      Describe the most remote, austere operating environment you faced? Any take homes from that experience?

One room OR with two OR tables in an old Soviet Era hardened structure.  Take home points: Forget about sterility expected in a US hospital OR, the casualties have wounds that likely more contaminated than an un-sterilized instrument in the OR.  Of course, we still followed the surgical principles and used sterile procedures and equipment.  In these austere settings, advanced, expensive, cumbersome medical technology is not as good as your/your team's knowledge and training and you/your team are the patient's best chance of survival.  The other basic necessities are lights, headlights (nothing fancy), electricity, sterilizer, basic general surgery, thoracic, vascular, and orthopedic sets, IV fluids, blood, and transfer facilities.

The overall take home point I would say is to take the time to read the lessons learned from the prior team if you are fortunate enough to have that resource.  There is no pride in delivering sub-optimal care while trying to reinvent the wheel.  Also as important, continue to learn from each experience, record it, and pass on your wisdom to the next team.  And wish them success.

5.      Was there any aspect of team leadership you predetermined you would be adept at but found needed improvement, or a total rehaul?

Coming from a busy trauma center, running a casualty resuscitation was second nature, but what I needed to do more of is team-building and preventing compassion fatigue.

6.      Any leadership aspect you had not considered or discounted that you found you had to learn on the fly?

What would have been useful is de-escalation techniques during confrontations, whether as a third party observer or directly involved.  Deployed individuals are stressed, fatigued, and prone to respond poorly to perceived slights or confrontation.  Leaders should stay vigilant of this tendency in themselves and others and respond with compassion and de-escalate the situation.

7.      When the teams form initially, do the members automatically register this concise preformed process or does the process not always work as well as you wished?

In general, when teams form, they naturally follow the model and do great without any catastrophes.  Viewing the evolution of team formation with this objectivity would help you see the bigger picture, anticipate likely scenarios, and to plan ahead.  In general, being social animals, people do well as a team.  It is only rarely that a member of the team may be maladjusted sociopaths who could sabotage your team.  These individuals should be removed from the team early if possible.  I see no other solution.

8.      How do you quiet the room when the commotion becomes distracting? Paul Lucha told me he just keeps turning his voice decibels quieter and quieter until everyone has calmed down (Paul Lucha, MD, FAC, CAPT, MC, USN, Retired; Department Head, Department  Surgery Navy Medical Center Portsmouth, VA.).

This aspect of commanding the room goes back to practicing drills and getting used to running actual resuscitations so that the team members associate the voice as the Trauma Team Leader.  Likely, there will be more than one TTL; we had several.  In this instance, a quick pre-brief that includes the team member's rolls should also clearly identify who the TTL will be and establish this hierarchy for a given casualty.  During the training, drilling, and coaching of a TTL candidate, they should be taught and reminded to assume the "command voice" which is not necessarily loud, but loud enough for most situations for all to hear and listen.  More importantly, it should be confident, precise, and succinct.  Deeper male voices seem to help, but I have seen many small female surgical residents assume this voice quite effectively, leading difficult resuscitations with authority.

One other technique is to "reboot" the room by reviewing the primary survey and current status of the patient to get everyone on the same wavelength to focus on the most important tasks at hand.

In addition, the other team members in the room should be empowered to practice crowd control - less people in the room equals less extraneous noise.  People talking about other topics besides the casualty or joking around should cease or be excused from the vicinity of the trauma bay.

9.      If a team member attempts to take control but is clearly wrong, how do you redirect them?

If the action is not life-threatening, then it can be discussed afterwards during the debrief and later during peer-review.  It may even be a learning point for all the team members and can be incorporated into didactic training.

If the wrong action will lead to harm for the patient, it must be stopped and corrected immediately.  The interaction and apologies for hurt egos can be discussed afterwards during the debrief.

10.     Any particular lesson learned about combat care you did not expect but sticks with you today? 

Having had a few sudden deaths in patients that appeared fairly stable when they were physiologically compensating, I still worry particularly about patients who on the surface seems to be doing unusually well despite severe injuries or mechanism of injury.

11.     Have you arrived at a treatment facility and just did not have time for orientation and rehearsals?

Fortunately, I have not had that experience.  Our team had time to work out the kinks with drills and had time to set up.  You would just have to trust that the training works and the team members you work with are also well trained.  If things are so rapid and chaotic, more communication among team members would be needed including their identification and role during the resuscitation.  If there are few minutes to spare prior to the arrival of the casualty, the pre-brief is useful to establish roles, ensure personal safety, review the basic steps through primary survey, secondary survey, and disposition plans.  Immediately debrief the team if time allows before the next casualty.

12.     Have you missed something that in looking back was obvious?

Allowing the team to decompress and hangout together is one major pillar that maintained a functional team.

13.     Did you ever receive a godsend help when you were praying for it that arrived from a source you least expected it?

An excellent CRNA who was able to place an IV on an infant in hemorrhagic shock when all IO's failed and I could not place a central line. 

14.     When you first started, what technique worked best for you in controlling your anxiety? What about controlling another's anxiety? Or maybe you never had a situation that did not pose a threat and therefore was not anxiety provoking?

Keeping physically fit kept me resilient to anxiety, but what exponentially helped that resilience was meditation.  It really works.  I would recommend it, just not the pseudoscience of some types of meditation trends.  As for anxiety in others, developing a strong emotional IQ to detect and ameliorate the others' anxiety would be my only advice.

15.     When you encounter a patient who has no chance for survival but clearly has their mental faculties totally intact what does one say to them?

If he has family and friends, they should be with them without me monopolizing the little time he has.  If there is no one, I would be there to listen to his requests, keep him comfortable, allay his fears, and not abandon him.

Thank you so much for your questions.  I enjoyed responding to them.  Please let us know if you have further questions.

Seon Jones, LCDR MC USNR

Kenneth A. Lipshy, MD, FACS

Gordon Wisbach, MD, CDR, MC, USN, Staff Surgeon, General Surgery Department

Lim RB. Surgery during natural disasters, combat, terrorist attacks, and crisis situations. New York. springer. 2016.

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